Form 86

H E A L T H

E X A M I N A T I O N

R E C O R D
Department of Education Sex: FEMALE Civil Status: SINGLE Date: Height: Weight: Temperature Respiratory System: Fluoroscopy: Sputum Analysis: Circulatory System Blood Pressure: Pulse: Sitting: Agility Test: Digestive System: Genito-Urinary: Urinalysis, etc.: Skin Locomotor System Nervous System Eyes: Conjunctivitis, etc. Color Perception: Vision With glasses: Far:______ Near: ______ W/o glasses: Far:______ Near: ______ Nose Ear: Hearing: Right: Left: Throat: Teeth and Gums: Immunization: Remarks: Recommendation: Employee’s Signature: Employee’s Name (Print): Physician’s Signature: Physician’s Name (Print):

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Name: MABETH T. TOYOGON Date of Birth: AUGUST 31, 1978 Date: Height: Weight: Temperature Respiratory System: Fluoroscopy: Sputum Analysis: Circulatory System Blood Pressure: Pulse: Sitting: Agility Test: Digestive System: Genito-Urinary: Urinalysis, etc.: Skin Locomotor System Nervous System Eyes: Conjunctivitis, etc. Color Perception: Vision With glasses: Far:______ Near: ______ W/o glasses: Far:______ Near: ______ Nose Ear: Hearing: Right: Left: Throat: Teeth and Gums: Immunization: Remarks: Recommendation: Employee’s Signature: Employee’s Name (Print): Physician’s Signature: Physician’s Name (Print):

Division: GENERAL SANTOS CITY Type of Work: TEACHING Date: Height: Weight: Temperature Respiratory System: Fluoroscopy: Sputum Analysis: Circulatory System Blood Pressure: Pulse: Sitting: Agility Test: Digestive System: Genito-Urinary: Urinalysis, etc.: Skin Locomotor System Nervous System Eyes: Conjunctivitis, etc. Color Perception: Vision With glasses: Far:______ Near: ______ W/o glasses: Far:______ Near: ______ Nose Ear: Hearing: Right: Left: Throat: Teeth and Gums: Immunization: Remarks: Recommendation: Employee’s Signature: Employee’s Name (Print): Physician’s Signature: Physician’s Name (Print):

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